In the summer of 2009 when the Patient Protection Affordable
Care Act, also known as the Affordable Care Act (ACA) and Obamacare, was being
widely discussed as a front burner political issue, I attended a town hall
meeting held by my congressional representative, a moderate democrat, to listen
to public comments before he decided whether or not to support the ACA. In the
years following the disappointing implosion of healthcare reform during the
Clinton administration, honestly, I did not expect to see the issue of
healthcare reform back on the political agenda in my lifetime. So I was eager
to attend and lend my support for a bill that would expand healthcare coverage
for Americans and to hear my congressman respond to questions. When I arrived I
was struck by the number of attendees and even more so by the large number of
signs and placards with crude slogans linking ACA death panels, Nazism, killing
grandma, etc. It was also striking that many of the people there were local
working people who were members of the newly formed Tea Party and fierce
opponents of the ACA. The negative views being expressed were passionate and
urgent: Passage of the ACA would take our country down a path toward socialism,
loss of freedom and government interference into the sacred domain of the
physician-patient relationship.

Now that the ACA has passed both chambers of congress, signed
by the president and ruled to be constitutional by the Supreme Court, there are
still strong efforts by it opponents to stop its implementation. At present,
the right wing of Republican Party in the house of representation has been
willing to shut down our government and threaten default on our national debt
unless the ACA is repealed or delayed. It is instructive to put the recent
efforts to derail the ACA into historical context and see them as an extension
of a century long effort, led by well-funded special interests groups to
motivate American citizens through misinformation and scare tactics to vote
against their own interests.

There have been a number of crucial points in the past 100
years of American history where proponents of reform initiatives to expand
healthcare coverage were sanguine about their chances of success only to be
defeated by a highly orchestrated and well-funded counter attack by special
interest groups. Although Theodore Roosevelt supported expanded healthcare
insurance the first real effort to expand healthcare coverage in 1915 came from
the American Association of Labor Legislation (AALL), which was supported by
the American Medical Association (AMA). By 1917 after the plan had been
rejected by many state medical societies and disagreement erupted about the
method of paying physicians, the AMA withdrew its support and denied ever
having supported it. It is interesting that criticism at this point also came
from both unions and commercial insurance companies. Unions worried that
government would replace their role of providing social benefits and insurance
companies feared a new, and more efficient, social framework for insuring
citizens that included items like funeral expenses, which would undermine the
multi-million dollar insurance industry. 1917 was also the year the US entered
WWI and this marked the beginning of the effectiveness of government commissioned
articles that linked universal healthcare with the risks of American moving
toward the German socialism and Russian communism. The early progressive
movement promoting healthcare reform, like many who followed them, did not
realize how opposing interest groups could so effectively promote their own
ideological and financial interests while simultaneously garnering public
support from the very citizens for whom expanded the benefits of expanded
healthcare were to be provided.

By the 1930’s as hospitals and their services were more
frequently utilized by more Americans, the issue of how Americans were going to
afford and pay for those services became an issue. The Committee on the Cost of
Medical Care (CCMC) funded by 8 major philanthropic organizations whose members
were a broad range of experts, had proposed by 1932 a system of voluntary
health insurance as a way to cover these growing costs. Because some of its
members favored compulsory health insurance, the AMA treated their report as a
radical approach to implement socialized medicine. With millions of American
out of work, the focus politically was on securing more benefits for the
elderly, which would have been put at risk if healthcare expansion in general
had been a goal. So it wasn’t until 1943, with the Wagner-Murray-Dingell Bill,
that there was proposal for compulsory national health insurance and a payroll
tax. Though many prominent leaders, including physicians, backed this plan,
there was a fierce opposition that linked it with communism and myths of
socialist world domination.

It is interesting that in 1944 governor Earl Warren of
California had garnered broad support, including the California Medical
Association, for a system of comprehensive healthcare insurance. However, it
was the California Medical Association who hired two seminal pioneers in
political consulting to wage a campaign against Warren’s plan and in support
for Californians to purchase their own insurance privately. The two
consultants, Clem Whitaker and Leone Baxter, spent their lives working jointly
from the late thirties through the early fifties. Together they created aggressive,
demagogic tactics to support big business by distorting the issues and instilling
fear by associating whatever program they were working against with an established,
mythical enemy. With the use of advertising slogans like “political medicine is
bad medicine” being used in newspapers throughout the state, the support for
Warren’s plan quickly diminished and it was defeated in 1945 by one vote.
Political advertising using mass medical was not about informing, but about
winning. That meant using tactics, however false and irrational, that worked to
change and mold public opinion.

It was also the efforts of Whitaker and Baxter over a period
of three years funded by the AMA at a total cost of nearly $5,000,000 that
successfully scuttled Harry Truman’s proposal for national health insurance in
the late 1940’s. In fact the AMA assessed member physicians an extra $25 each
to help pay for this campaign which again effectively associated universal
healthcare insurance with socialism and communism. The failure to expand
government provided healthcare insurance was the framework in which unions
negotiated benefits with employers, which resulted in the unique feature of the
American healthcare system that links healthcare insurance with employment. But
the game plan for undermining an effort to expand healthcare insurance, which
persists to this day, had been defined in the 1940’s by Whitaker and Baxter.

The only grass roots movement by the late 1950’s to expand
access to healthcare was on behalf of the elderly and the most vulnerable,
which resulted in Medicare and Medicaid in 1965. As expected, the AMA opposed
the initial plans and countered with a plan that included a voluntary program. Ronald
Reagan summarized the prevailing conservative view in the following statement:
“One of the traditional methods of imposing statism or socialism on a people
has been by way of medicine. It’s very easy to disguise a medical program as a
humanitarian project. Most people are a little reluctant to oppose anything
that suggests medical care for people who possibly can’t afford it.” The
linkage between universal healthcare and the threat of socialism runs deep in
much of conservative political thinking. Richard Nixon was somewhat of an
exception as he proposed a plan to reform the healthcare system through private
insurance and to expand coverage in a manner that resembles what we see today
in the ACA. Ted Kennedy resisted this approach and held out for an outright
single payer system in the 1970’s. Certainly by the time Reagan became
president, Kennedy’s noble aspirations were seen more and more as a liberal
perspective not suitable for American capitalism.

In 1992 Bill Clinton campaigned on healthcare reform in 1992
and came into office with the unusual political capital to actually make reform
happen. There was for a brief time a political consensus that healthcare reform
was going to happen. Though the result was not going to be the robust single
payer system Kennedy envisioned, but rather a more market based approach. Sadly,
the plan that emerged became vulnerable to attacks for its complexity and also
for not being more inclusive in its formulation. As soon as the criticisms
began, all the traditional opponents of universal healthcare came on board and
the effort quickly died. In retrospect, it should have been evident that
conservatives were going to be against any healthcare reform plan a democratic
president proposed. With the election of G. W. Bush, the prospects of
healthcare reform were non-existent, except for Medicare prescription drug
reform, which was a massive expansion of healthcare benefits, but one that
failed to use the bargaining power of government to control cost and therefore
caused a significant increase in the national deficit.

Though President Obama talked about healthcare reform in the
2008 campaign, though not universal coverage, and saw it as a fundamental
structural barrier to economic progress, there were many challenges to getting it
on the political agenda. In spite of many overtures of offers to cooperate from
Republicans, by the summer of 2009 much time has been wasted on delay tactics
and many of us thought the ACA proposal did not have a great chance to become
law. Still it was the first time since the defeat of Truman’s plan that a real
proposal had been presented for national discussion. It is somewhat ironic that
the ACA was a plan similar to what Nixon had in mind in the early 70’s, and
very similar to what the conservative Heritage Foundation came up with in the
early 1990’s as an alternative to a single payer system, and basically what
Mitt Romney passed and implemented in Massachusetts. But when Obama proposed
the ACA it prompted well-funded conservative organizations to fund the Tea
Party and with the help of right wing media outlets, the result was a wave of
hysteria about the extremist nature of the ACA. This groundswell of public
reaction in the form of the Tea Party was the basis for the GOP to take control
of the House of Representatives in 2010; and, sadly, the moderate democratic
representative from my district was defeated. Though the ACA is clearly on the
conservative side of healthcare proposals, it has received criticism by the Tea
Party as though it was a state controlled single payer system and with less
than noble intentions about providing healthcare to Americans.

The
political consulting work of Whitaker and Baxter was possibly the first use of
mass media to control a political message. But in the subsequent decades it has
been taken to a high political art and seems to permeate American politics. As
our nation has grappled with a government shutdown and faced a national default
on its debt, which would have had catastrophic consequences for both the
national and global economies, one realizes how far out of touch contemporary
American political discourse is with the healthcare challenges that face our
nation. One also realizes the lengths to which special interests will go to prevent
change in the current healthcare system so they can protect their own economic
interests. The legacy of special interests vis-à-vis healthcare reform is not
only a national disgrace but also has become a serious national liability to
the future of our nation.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

References

Karen S. Palmer. A brief history: Universal healthcare
efforts in the U.S. (http://pnhp.org)

Jill Lepore. The lie factory: How politics became a
business. The New Yorker (9-24-12)

Comments

Sadly? The Democrats built Albany. A high tax disaster with the 4th worst school in NYS. A huge population on welfare and crime that goes unreported in the news. That is another topic and one completely unrelated to the ACA. The healthcare program in Mass. is a mess. It didn't work there and it won't work for USA. It serves only as a stepping stone to a single payer system. Healthcare spending in Mass is 15% higher than the national average with the highest individual plan rates in the country, why? In 2004 they ranked #1 for costs per capita and in 2013 they haven't moved much, #2 I think only to Alaska or DC, again, why? Nine years of RomneyCare and virtually nothing has improved in fact it arguably got worse. Those numbers are also with the federal government funding 64% of Romneycare, Mass kicking in 18% and hospitals paying the rest. Funny, when people compare RomneyCare to ACA they neglect to discuss the incredible failures of it as well as the cost sharing and funding sources. The ACA is based on taxes and enrollment only. So answer me this, will Albany Medical Center be another one of the major medical centers to opt out of a majority of the Obamacare plans? If it is so great why are they bailing? Was and is healthcare reform needed? Yes. It could have been accomplished with a few small scale laws prohibiting pre-existing condition exclusions as well as opening up plan competition nationally so people could shop rates and thereby drive costs down. Insurance companies are just part of the healthcare problem. The other part is the absurdly high prices charged for tests, drugs, and care. Lawyers and their huge settlements drove up malpractice insurance as well. A lot could have been done before the ACA was necessary. Big government programs aren't always the answer. I can't think of a single one that worked and isn't broke or being used as a source of funds for unrelated projects. Is it political? Yes, of course it is. The Democrats just took on something very personal, very expensive, and very difficult to manage. If they continue to blow it they will never live it down. I wish them luck, I think it is going to get much worse before it gets better.